OBJECTIVES

To examine the evolution of advanced public health nursing (APHN) roles that address extant, complex community level problems such as rural substance abuse.

To apply an ethnographically-informed and community participatory model of community and environmental assessment as the basis for designing a rural youth substance use prevention program.

To describe the core PHN competencies that undergird evolving community participatory APHN roles.

INTRODUCTION

PHN practice is population-focused requiring unique knowledge, competencies, and skills.

Early PHN roles extended beyond sick care to encompass advocacy, community organizing, health education, and political and social reform.

Contemporary public health nurses practice in collaboration with agencies and community members.

INTRODUCTION

At an advanced level, PHN knowledge and competencies challenge nurses to take a leadership role:

To assess the assets and needs of communities and

populations and

To propose solutions through partnership.

Community- or population-focused solutions have widespread influence on health and illness patterns of multiple levels of clients including:

Individuals, families, groups, neighborhoods,

communities, and the broader population (ACHNE, 2003).

BACKGROUND AND HISTORY Health care as healing, or treating those already sick,

maintained dominance over preventive care for centuries.

As preventive health care emerged during the mid-19th

century, a moral tension arose between giving resources to

the needy and teaching them how to meet their own needs.

Early PHN struggled with the role and continues to struggle

with appropriate interventions that will achieve quick results,

but also have lasting improvements in the population.

BACKGROUND (CON’T)

PHN initiatives in advocacy, community

organizing, and political reform to improve

the health of populations:

Lillian Wald, 1900’s, New York City.

Mary Osborne, 1920’s, Mississippi.

Nancy Milio, 1960’s, Detroit.

THE COMMUNITY PARTICIPATION AND

ETHNOGRAPHIC MODEL (KULBOK ET AL., 2012)

Builds on community-based participatory research (CBPR) by

engaging community members and leaders in action steps from

problem identification to project evaluation and dissemination.

CBPR is:

grounded in critical and social action theory;

builds partnerships with community members across SES;

focuses on community assets and resources rather than on deficits; and,

seeks balance between the community and practitioners through shared

leadership, co-teaching, and co-learning opportunities (Israel, Eng, Schulz, &

Parker, 2005).

THE MODEL (CON’T)

Socio-cultural contexts, systems, and meaning emerge through

collaboration between public health nurses and community

members.

Ethnographic work in substance use prevention provided a

foundation for the model (Agar, 1973; Agar, 1986; Karim, 1997; Trotter, 1993). Local community knowledge of substance nonuse and use to provide a rich

understanding of health assets and community needs;

The environment surrounding substance-related health and illness,

Community and population conditions; and

Attitudes, beliefs, and traditions related to substance nonuse- or use. 1997).

Teen/Parent Photovoice

Teen/Parent Group

Discussions

Ethnographically Informed

Community Assessment and

Mapping

Community

Leader

Interviews

Community Partnership Approach (CPRT)

Community Drug Prevention and Program

Manual for Rural Youths and Parents

Community Core and History

Physical Environment

Idea Systems

Social systems

Behavioral Patterns

(Adapted from Aronson

and colleagues, 2007)

Figure 1. A Community Participation and Ethnographic Model

YOUTH SUBSTANCE USE Rural communities have high rates of smoking and

smokeless tobacco use and tobacco use is correlated with

alcohol and other drug use.

Healthy People 2020 points to long-term health threats of

youth substance use and the need to increase the

proportion of youth who remain substance free (DHHS, 2010).

Yet many rural counties have little knowledge of effective

strategies to prevent substance use.

THE PROJECT Duration: Three years

Community based participatory team (CPRT):

Interdisciplinary researchers and community members (4 community

leaders, 12 youths, and 8 parents)

Aims/Phases:

Establish the CPRT

Conduct community assessment

Create prevention program effectiveness criteria

Pilot youth substance use prevention program

Methods:

Community assessment, Interviews (Community leaders, youth, and

parents), Photovoice, GIS mapping, and Ethnographic approach

COMPETENCIES FOR COMMUNITY

PARTICIPATORY ROLES

Analytic assessment skills

Active communication to gain in-depth insights about the

community’s assets and needs

Cultural competence skills

Understand invisible factors in the community that promote health,

such as assets, values, and strengths, to give voice and empower

diverse sub-groups and populations.

COMPETENCIES FOR COMMUNITY

PARTICIPATORY ROLES

Program planning skills

Plans population‐level interventions guided by relevant theories,

concepts, models, policies, and evidence.

Community dimensions of practice skills

Uses input from a variety of community/aggregate stakeholders in

the development of public health programs and services.

PHN CORE COMPETENCIES

Domain 1: Analytic and Assessment Skills

Domain 2: Policy Development/Program Planning Skills

Domain 3: Communications Skills

Domain 4: Cultural Competency Skills

Domain 5: Community Dimensions of Practice Skills

Domain 6: Public Health Sciences Skills

Domain 7: Financial Management and Planning Skills

Domain 8: Leadership and Systems Thinking Skills

DISCUSSION Complex, behavior-driven health problems, such as

substance abuse, obesity, and violence require creative and

innovative interventions firmly based in the community.

A “cookie cutter” approach to community or population

interventions is not likely to be effective.

Interventions that “fit” a community and engage multiple

stakeholders are essential for sustainability.

DISCUSSION Nationally vetted interventions for complex community problems

may come in the form of “toolkits” with many optional programs

and interventions to choose from.

Use of the Community Participation and Ethnographic Approach

can take advantage of these rigorously designed interventions, but

increase the likelihood that they “fit” the community.

The community participatory process gives structure to the people

and methods involved in selecting or designing interventions.

DISCUSSION

Education of advanced practice PHN’s should

include these competencies So PHN’s are prepared to take leadership roles in community

participatory, multi-sectoral interventions

To address some of the toughest health issues in our present

and future.

The community participatory process gives

structure to the people and methods involved in

selecting or designing interventions.

REFERENCES Agar, M.H. (1973). Ethnography and the addict. In: Nadar, L., and Maretzki, T.W., (eds.) Cultural Illness and

Health. Washington, DC: American Anthropological Association.

Agar, M.H. (1986). Speaking of Ethnography. Beverly Hills, CA: Sage Publications

Aronson, R.E., Wallis, Anne B., O’Campo, P.J. & Schafer, P. (2007). Neighborhood mapping and evaluation:

A methodology for participatory community health initiatives. Maternal Child Health Journal, 11, 373 –

383.

Aronson, R.E., Wallis, A.B., O’Campo, P.J., Whitehead, T.L., & Schafer, P. (2007). Ethnographically informed

community evaluation: A framework and approach for evaluating community-based initiatives. Matern

Child Health J, 11, 97-109.

Karim, G. (1997). In living context: An interdisciplinary approach to rethinking rural prevention. In E.B.

Robertson, Z. Sloboda, G.M. Boyd. L. Beatty & N.J. Kozel, eds. Rural substance abuse: State of

knowledge and issues (National Institute of Drug Abuse, Monograph 168). Rockville MD: US

Department of Health and Human Services.

Kulbok, P.A., Thatcher, E., Park, E., Meszaros, P.S. (May 31, 2012). Evolving public health nursing roles:

focus on community participatory health promotion and prevention. OJIN: the online journal of issues

in nursing vol. 17, no. 2, manuscript 1.

REFERENCES (CON’T)

Lundy, K. S., & Bender, K. W. (2001). History of community health and public health nursing, in Community

Health Nursing: Caring for the Public’s Health. Sudbury, MA: Jones and Bartlett.

Milio, N. (1970). 9226 Kercheval: The storefront that did not burn. Ann Arbor, MI: University of Michigan

Press.

Minkler, M. & Wallerstein, N. (eds) (2003). Community-Based Participatory Research for Health. San

Francisco, CA: John Wiley & Sons, Inc.

Stanhope, M., & Lancaster, J. (2011). Public health nursing: Population-centered care in the community (8th

ed.). St. Louis, MO: Mosby.

Trotter, R. (1993). Ethnographic methods and inhalant use among three ethnic populations. Paper

presented at the Inhalant Conference, Fort Collins, CO, August 1993.

Wang, CC and MA Burris, “Empowerment through Photovoice: Portraits of participation.” Health Education

Quarterly ,Vol. 21(2): 171-186. 1994.